Healthcare Provider Details

I. General information

NPI: 1669070918
Provider Name (Legal Business Name): TRI-CITY DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 COLUMBIA POINT DR STE 105
RICHLAND WA
99352-4390
US

IV. Provider business mailing address

84827 JENNA LN
KENNEWICK WA
99338-7311
US

V. Phone/Fax

Practice location:
  • Phone: 509-873-7140
  • Fax: 509-818-1303
Mailing address:
  • Phone: 484-919-2125
  • Fax: 509-530-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY W PECK
Title or Position: OWNER/MD
Credential: MD
Phone: 509-873-7140